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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609859
Report Date: 12/21/2022
Date Signed: 12/22/2022 09:02:31 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2022 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20221018142721
FACILITY NAME:WILLOUBEE RESIDENTIAL IIIFACILITY NUMBER:
197609859
ADMINISTRATOR:HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:3631 E GARNET LANETELEPHONE:
(661) 350-3495
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 3DATE:
12/21/2022
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Chanel Williams, StaffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Residents do not have access to toiletries.

Staff not providing adequate food service.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit for the above noted allegations. LPA met with Staff Chanel Williams. The purpose of the visit was discussed.

It was reported that residents do not have access to toiletries. To investigate this allegation on 12/21/2022 between 1:50pm and 2:10pm, LPA conducted a physical plant tour. LPA observed very few toiletries kept in a closet. LPA saw one toothpaste, one deodorant, and three shampoos. Between 1:40 and 2:00pm, resident interviews were conducted. Interviews revealed that they are not allowed to enter the room where the toiletries are kept.

Based on observation and interviews there is sufficient information to support this allegation. Therefore, this allegation is being SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20221018142721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE RESIDENTIAL III
FACILITY NUMBER: 197609859
VISIT DATE: 12/21/2022
NARRATIVE
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It was reported that Staff are not providing adequate food service. To investigate this allegation on 12/21/2022 between 1:50pm and 2:10pm, LPA conducted a physical plant tour. LPA observed an extremely limited supply of food. LPA only saw one egg, no meats, no vegetables, no milk, no bread and old fruit on the kitchen counter. The non-perishable seven day food supply was also observed to be low. Between 1:40pm and 2:00pm, resident interviews were initiated. Resident interviews revealed that there is no food at the facility and therefore they are left hungry most of the time. At 2:50pm, LPA reviewed the menu and confirmed that it did not provide an adequate food service.

Based on observation and interviews there is sufficient information to support this allegation. Therefore, this allegation is being SUBSTANTIATED.

Deficiencies were cited.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20221018142721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOUBEE RESIDENTIAL III
FACILITY NUMBER: 197609859
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2022
Section Cited
CCR
80076(a)(1)
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80076(a)(1) Food Services- In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in quantity necessary to meet the needs of clients...

This requirement was not met as evidenced by:
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The Licensee shall submit in writing to CCLD how they will ensure that there is enough perishable and non-perishable food to meet the dietary needs of clients by 12/28/2022.
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The Licensee did not ensure that there was enough perishable and non-perishable food to meet the dietary needs of clients.

This poses an immediate health and safety risk to clients in care.
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Type B
12/28/2022
Section Cited
CCR
80072(a)(2)
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80072(a)(2) Personal Rights- (a)...each client shall have personal rights which include, but are not limited to the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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The Licensee shall submit in writing to CCLD how they will ensure that there are sufficient accesible toiletries to meet the needs of clients by 12/28/2022.
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The Licensee did not ensure that clients are provided sufficient toiletries that are accessible to them.

This poses a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3